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Medical Schemes Act, 1998 (Act No. 131 of 1998)


Regulations in terms of the Medical Schemes Act


Annexure A

Explanatory notes and definitions to Annexure A


1) Interventions shall be deemed hospital-based where they require:


An overnight stay in hospital; or
The use of an operating theatre together with the administration of a general or regional anaesthetic; or
The application of other diagnostic or surgical procedures that carry a significant risk of death, and consequently require on-site resuscitation and/or surgical facilities; or
The use of equipment, medications or medical professionals not generally found outside of hospitals.


2) Where the treatment component of a category in Annexure A is stated in general terms (i.e. "medical management" or "surgical management", it should be interpreted as referring to prevailing hospital-based medical or surgical diagnostic and treatment practice for the specified condition. Where significant differences exist between Public and Private sector practices, the interpretation of the Prescribed Minimum Benefits should follow the predominant Public Hospital practice, as outlined in the relevant provincial or national public hospital clinical protocols, where these exist. Where clinical protocols do not exist, disputes should be settled by consultation with provincial health authorities to ascertain prevailing practice. The following interventions shall however be excluded from the generic medical / surgical management categories unless otherwise specified:
i) Tumour chemotherapy
ii) Tumour radiotherapy
iii) Bone marrow transplantation / rescue
iv) Mechanical ventilation
v) Hyperbaric oxygen therapy
vi) Organ transplantation
vii) Treatments, drugs or devices not yet registered by the relevant authority in the Republic of South Africa


2A) In respect of treatments denoted as "medical management" or "surgical management," note (2) above describes the standard of treatment required, namely "prevailing hospital-based medical or surgical diagnostic and treatment practice for the specified condition." Note (2) does not restrict the setting in which the relevant care should be provided, and should not be construed as preventing the delivery of any prescribed minimum benefit on an outpatient basis or in a setting other than a hospital, where this is clinically most appropriate.


3) "Treatable" cancers. In general, solid organ malignant tumours (excluding lymphomas) will be regarded as treatable where:
i) they involve only the organ of origin, and have not spread to adjacent organs
ii) there is no evidence of distant metastatic spread
iii) they have not, by means of compression, infarction, or other means, brought about irreversible and irreparable damage to the organ within which they originated (for example brain stem compression caused by a cerebral tumour) or another vital organ
iv) or, if points i. to iii. do not apply, there is a well demonstrated five year survival rate of greater than 10% for the given therapy for the condition concerned


4) Tumour chemotherapy with or without bone marrow transplantation and other indications for bone marrow transplantation.

These are included in the prescribed minimum benefits package only where Annexure A explicitly mentions such interventions. Management may include a first full course of chemotherapy (including, if indicated, induction, consolidation and myeloablative components). Where specified in terms of Annexure A, this may be followed by bone marrow transplantation/rescue, according to tumour type and prevailing practice. The following conditions would also apply to the bone marrow transplantation component of the prescribed minimum benefits:

i) the patient should be under 60 years of age
ii) allogeneic bone marrow transplantation should only be considered where there is an HLA matched family donor
iii) the patient should not have relapsed after a previous full course of chemotherapy
iv) (points i. and ii. shall also apply to bone marrow transplantation for non-malignant diseases)


5) Solid organ transplants. The prescribed minimum benefits Annexure includes solid organ transplants (liver, kidney and heart) only where these are provided by Public hospitals in accordance with Public sector protocols and subject to public sector waiting lists.


6) In certain cases, specified categories shall take precedence over others present. Such "overriding" categories are preceded by the sign "#" in their descriptions within Annexure A. For éxample, where someone is suffering from pneumonia and HIV, because the HIV category (168S) is an overriding category, the entitlements guaranteed by the ‘pneumonia’ category (903D) are overridden.


7) Hospital treatment where the diagnosis is uncertain and/or admission for diagnostic purposes. Urgent admission may be required where a diagnosis has not yet been made. Certain categories of prescribed minimum benefits are described in terms of presenting symptoms, rather than diagnosis, and in these cases, inclusion within the prescribed minimum benefits may be assumed without a definitive diagnosis. In other cases, clinical evidence should be regarded as sufficient where this suggests the existence of a diagnosis that is included within the package. Medical schemes may, however, require confirmatory evidence of this diagnosis within a reasonable period of time, and where they consistently encounter difficulties with particular providers or provider networks, such problems should be brought to the attention of the Council for Medical Schemes for resolution.


8) NOS - not otherwise specified


9) In respect of Code 902M (Diagnosis: Infertility), ‘medical and surgical management’ shall be limited to the following procedures or interventions :
a) hysterosalpingogram
b) the following blood tests:
i) Day 3 FSH/LH
ii) Oestradiol
iii) Thyroid function (TSH)
iv) Prolactin
v) Rubella
vi) HIV
vii) VDRL
viii) Chlamydia
ix) Day 21 Progesterone
c) laparoscopy
d) hysteroscopy
e) surgery (uterus and tubal)
f) manipulation of ovulation defects and
g) deficiencies
h) semen analysis (volume; count; mobility;
i) morphology; MAR-test)
j) basic counseling and advice on sexual
k) behaviour, temperature charts etc.
l) treatment of local infections.